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_,e,: <br /> ll <br /> SAN JOAQUIN LOCAL IiEALTH DISTRICT(-P 1 �)0 <br /> FOF dF__FICE 'US E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ���_� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l -7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. 4 <br /> / <br /> JOB ADDRESS/LOCATION _� �� 1! A4 r CENSUS TRACT 2�S•�J� J <br /> Owner's Name �. ' c, .f-c... Phone <br /> Address City <br /> E <br /> Contractor's Name j tf-!� Aa 14 1 • ,L4 CO License #3fi5753`PhoneIF Ir <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP'INSTALLATION / / PUMP REPAIR / I PUMP REPLACEMENT /-7 j Q , <br /> ~ Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> _- SEWAGE DISPOSAL-FIELD CESSPOOL/SEEPAGE-PIT '° """ OTHER <br /> PROPERTY "L•INE •- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL : CONSTRUCTION SPECIFICATIONS i <br /> Industrial 'Cable Tool Dia. of Well IExcavation E Domestic/private Drilled Dia. of Well Casing !F <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal IM <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' 0 <br /> Geophysical Surface Seal Instal-led-By: iM , <br /> PUMP INSTALLATION: Contractor A)*I$ o "fe IL70 H <br /> Type' of PumpH.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> 4 <br /> k PUMP ,.REPAIR: / / State Work Done <br /> Approximate i� <br />� DES-TRUCTION OF WELL: Well Diameter A Pp Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the.-well in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED J TITLE 13t� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I > �� <br /> APPLICATION ACCEPTED BY ljtl DATE/ <br /> 1 <br /> ADDITIONAL COMMENTS: :F <br /> PHASE II GROUT INSPECTION P SE /FIN INSPECTI N ' <br /> INSPECTION BY DATE;/ INSPECTION BY DATE <br /> I77J 2M <br />